Persistent racial disparities in neonatal mortality rates are a major public health concern. Black neonates are more than twice as likely to die as white neonates. In previous research in New York City (NYC) hospitals, we found nearly a three-fold variation in risk-adjusted very low birth weight (VLBW) neonatal mortality rates among hospitals and black infants were much more likely to be born at higher mortality hospitals. The factors that influence wide variation in mortality rates among hospitals are not known. Why black women are more likely to deliver at higher mortality hospitals is also unknown. The objectives of this study are: 1) To examine risk- adjusted neonatal mortality among New York City hospitals over the past decade and assess the extent to which variations in hospital quality contribute to VLBW mortality disparities for blacks and Latinos; 2) To use an innovative mixed methods approach to explore processes of care, unit characteristics, patient factors, and organizational factors that explain differences in hospital quality as measured by overall and cause-specific risk-adjusted mortality rates and use of evidence-based practices; 3) To explore patients' perspectives on barriers to receipt of high quality care by exploring barriers to timely care, communication, availability of high risk obstetrics care, knowledge, decision-making regarding delivery hospital, and perception of risk; and 4) To create specific strategies with key stakeholders to promote uptake of best practices at hospitals caring for VLBW infants including patient-centered strategies to minimize barriers to receipt of high quality care. Methods: In Phase 1, we will use NYC Vital Statistics records linked with New York State Discharge Abstract Data to develop a risk-adjusted VLBW neonatal mortality model. We will use this model to rank hospitals based on risk-adjusted mortality. We will then examine the distribution of black, Latino, and white births among hospitals. In Phases 2 and 3 we will use both quantitative and qualitative methods to determine which hospital factors and practice patterns may explain the wide variation in mortality outcomes among hospitals and to explore why black mothers deliver in higher mortality hospitals. We will then convene leaders of obstetrics and neonatologists, hospital quality leaders, community leaders, NYC and State Departments of Health, and patients to discuss our results and explore interventions to improve care for VLBW infants. Information from this study will provide a better understanding of quality in neonatal care in hospitals and reveal specific processes of care that can be improved upon to reduce racial/ethnic disparities in neonatal outcomes.